A 31-year-old lady with a history of cholecystectomy five years back presented with cholestatic jaundice for one-year, increasing over the last two months with fever for one week. Examination revealed icterus and hepatomegaly. Investigations revealed leukocytosis (TLC, 15.4 × 103/µL) and deranged liver function tests (bilirubin, 19.5 mg/dL; aspartate transaminase [AST], 98 IU/L; alanine transaminase [ALT], 50 IU/L; alkaline phosphatase [ALP], 380 IU/L). Magnetic resonance cholangiopancreatography (MRCP) showed dilated right posterior hepatic duct (Fig. 1A). On endoscopic retrograde cholangiopancreatography (ERCP), initial cholangiogram showed prominent common bile duct (CBD) with normal intra-hepatic biliary radicals. Due to discrepancy with MRCP, an occlusion cholangiogram was taken, which revealed a dilated ductal structure arising from the cystic duct area with intervening stricture (Fig. 1B–D). Attempted selective cannulation of this dilated duct was unsuccessful. On endoscopic ultrasound (EUS), aberrant dilated duct arising from cystic duct remnant and draining right posterior hepatic segments was identified. This was punctured with 19G EUS-fine-needle aspiration (FNA) needle and transmural drainage into duodenum was attained with 10F double pigtail technique (DPT) stent (Fig. 2). Fever resolved with marked improvement of liver functions (bilirubin, 3.1 mg/dL) at one-month follow-up. Feasible long-term management options include percutaneous or EUS-guided rendezvous with stricture dilatation, surgery or repeated stent exchanges every three months to keep the choledochoduodenostomy patent.
Fig. 1
A Magnetic resonance cholangiopancreatography (MRCP) showing aberrant dilated right posterior hepatic duct (orange arrow); B initial cholangiogram showing apparently normal intra-hepatic biliary radicals with prominent common bile duct (CBD); C balloon occluded cholangiogram showing dilated ductal structure (green arrow) arising from cystic duct area with intervening stricture (yellow arrow); D schematic representation of biliary anatomy in our patient ((i) left hepatic duct, (ii) right hepatic duct, (iii) common hepatic duct, (iv) cystohepatic duct, (v) cystohepatic duct stricture)
Fig. 2
A Endoscopic ultrasound (EUS) image from first part of duodenum showing aberrant dilated duct (white arrow) arising from cystic duct remnant and draining right posterior segments (orange arrow: right portal vein; blue arrow: left portal vein); B guidewire in aberrant cystohepatic duct, which is partially opacified with contrast following puncture with 19G EUS-fine-needle aspiration (FNA) needle; C trans-mural drainage of aberrant cystohepatic duct into first part of duodenum attained using 10 F double pigtail plastic stent
Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the systemic effects of menopause, so you can help patients in your clinics through the transition.
Growing numbers of young people are using e-cigarettes, despite warnings of respiratory effects and addiction. How can doctors tackle the epidemic, and what health effects should you prepare to manage in your clinics?
Frailty has a significant impact on health and wellbeing, especially in older adults. Our experts explain the factors that contribute to the development of frailty and how you can manage the condition and reduce the risk of disability, dependency, and mortality in your patients.
Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date.